In an age of globalized medical education, medical school accreditation has been hailed as an approach to external quality assurance.1–4 In 2010, the Educational Commission for Foreign Medical Graduates (ECFMG) and the World Federation for Medical Education (WFME) announced a joint initiative to ensure that medical school accrediting agencies are “at an internationally accepted and high standard” by 2023.5 Upon this deadline, the ECFMG will limit its certification of international medical graduates (IMGs) to graduates of medical schools accredited by authorities recognized by the WFME for accreditation standards “comparable” to “globally accepted criteria,”6 such as those produced by the U.S. Liaison Committee on Medical Education (LCME) and by the WFME. This announcement will likely influence many countries to aim for WFME recognition because ECFMG certification determines the eligibility of IMGs to enter medical training and practice in the United States. As of September 2017, seven accreditation agencies in the Caribbean, Turkey, United States, Canada, South Korea, and Japan have achieved WFME recognition.5 Yet, it is unclear how national accreditation bodies can develop standards suitable for both local contexts and international recognition.
Global accreditation is intended to address concerns around international medical education, such as ensuring key competencies, skills, and knowledge among an increasingly mobile pool of health professionals and students.7–9 Yet, this global focus could lead to country-specific health needs being overlooked.1,10,11 Hodges et al1 raise an important question: “Is it possible to consider global accreditation without reverting to colonialism and all of the problematic baggage associated with homogenization and cultural dominance?”
Cross-cultural research in medical education emphasizes differences between countries in the definition and assessment of key competencies, such as professionalism.8,10,12,13 Focusing on Mexico, Hosseini et al14 argue that context-specific definitions of the physician’s role in society should inform accreditation of medical education and evaluation of competencies; direct importation of outside standards “cannot be considered an appropriate solution.” Nevertheless, some national accreditation bodies have adopted externally developed standards.15 How might these countries benefit from participating in a globalized system of accreditation while also meeting local needs? Further research on accreditation’s global and local dimensions is needed to shine light on a complicated process involving many stakeholders.7
In this study, we frame the issue of medical school accreditation in terms of “glocalization,” a portmanteau combining globalization and localization. As a sociological and business concept, glocalization involves the crafting of services, products, and ideas to address both the universal and the particular.16–18 In medical education, “glocal” physicians are equipped with the skills and knowledge to adapt to changing global and local contexts.19 In the context of accreditation, globalization refers to the adoption of international reference standards, and localization refers to the adaptation of external standards for local contexts. Thus, glocalization refers to accreditation that addresses both global and local requirements—for example, by using standards developed by international agencies as a benchmark while adapting those standards to local needs.
With regard to glocalization, the WFME acknowledges that “[n]ot all standards may have application in every setting” and suggests that accreditation bodies should “review the relevant standards and develop a version of them that is appropriate to the local context.”20 This guideline is valuable but limited as it does not specify a minimum acceptable degree of alteration or omission, nor does it discuss which factors should be taken into account. The cost of developing and implementing accreditation could lead the risk-averse with limited resources to over-rely on the example sets of standards produced by the WFME.21 Further guidance is needed on how to revise global standards in a manner that both responds to local contexts and meets international benchmarks.
To address the above issues, we explored medical school accreditation in Taiwan, Japan, and South Korea. We compared how these three East Asian countries have adapted international accreditation standards to address domestic and global demands simultaneously.
National Accreditation: Choosing and Using Reference Standards
The three countries included in this study share overlapping circles of political, economic, and cultural influence, extending into medical education and accreditation. The first medical schools in Taiwan and South Korea were established by the Japanese colonial government.22 Today, medical education systems in the three countries retain some similarities, including undergraduate entry. Yet there are some differences in their medical education systems and, related to this, in their approaches to accreditation.
The Taiwan Medical Accreditation Council (TMAC) was established in 2000. The earliest version of TMAC’s accreditation standards (2000) integrated the existing guidelines for university accreditation from the Ministry of Education (MoE) with U.S. and Australian practices. The National Committee on Foreign Medical Education and Accreditation (the authority that determines eligibility for participation in the U.S. federal student loan program) reviewed Taiwan’s accreditation standards in 2002 and 2009 and concluded that the standards were “comparable” to those used in the United States.23,24 Following an extensive consultation process involving both local and global stakeholders, including experts from the LCME and the Foundation for the Advancement of International Medical Education and Research, TMAC’s 2013 (current) standards25 were developed using the 2008 version of the LCME standards26 as a template (see Table 1).
TMAC adopted the structure of the LCME 2008 standards because of their numbered format and “enforceable” phrasing27 as well as the LCME’s long-standing global reputation. Surveyors had struggled to precisely cite the earlier TMAC standards, which were written in prose format. In the 2013 standards, TMAC retained its standards from past iterations wherever there was significant overlap with the LCME standards.
In 1999, South Korea piloted an accreditation program with 10 newly established medical schools using a set of 50 standards. All 41 Korean medical schools28,29 participated in the 2000 and 2005 cycles, and 40 schools passed with conditional or full accreditation. To encourage a globally competitive level of medical education, the Korean Institute of Medical Education and Evaluation (KIMEE) revised its standards in 2014,30 referencing the General Medical Council’s (GMC’s) Tomorrow’s Doctors31 in addition to the LCME 200826 and WFME 200332 standards (see Table 1).
KIMEE drafted its standards using the Korean MoE’s framework for university evaluation. In addition, as noted above, KIMEE incorporated some elements of international standards published by the GMC, LCME, and WFME. Responding to the ECFMG-WFME initiative, KIMEE will revise its standards in 2018, modeling them on the WFME 2015 standards.33 To ensure buy-in from medical schools, KIMEE plans to incorporate WFME standards related to innovations, which it expects to be popular among medical schools because of the WFME’s global authority and the perception that the WFME standards were crafted through collaboration and consensus.
The ECFMG-WFME announcement6 in 2010 set accreditation into motion in Japan. In 2013, a committee of deans and the Japanese MoE jointly agreed to found the Japan Accreditation Council for Medical Education (JACME), and eight schools participated in trial accreditation. The formal establishment of JACME took place in December 2015, after all 80 established medical schools agreed to the system’s formation and contributed fees.34 Formal accreditation started in April 2017, after JACME achieved WFME recognition. All medical schools will now be evaluated according to the formal accreditation process. The current (2017) JACME standards35 reference the WFME 2015 standards33 as a template. The LCME standards were also considered, but they were deemed unsuited to Japan’s undergraduate-entry medical education system because they were developed for a postbaccalaureate system.
JACME initially adopted the WFME 2012 standards and annotated 11 of the 36 standards. These annotations modified the meaning of the original standards, clarified terminology, or specified their interpretation in the Japanese context. The WFME standards were revised in 2015. Accordingly, JACME adopted the 36 WFME 2015 standards,33 annotating 11 in the JACME 2016 standards36 (see Table 1).
This study employed a comparative case-study design. We selected Taiwan, Japan, and South Korea on the basis that medical school accreditation bodies in each of these countries had developed national standards using international reference standards. We selected multiple countries within a common world region to contain the risk of overgeneralizing from a single country case. Following a qualitative, constructivist approach, we employed document analysis, performed by a mix of “insider” and “outsider” researchers.37 National insiders included D.A., M.J.H., C.W.L., and N.N., medical educators who have played leading roles in their national accrediting bodies. J.A. and K.S. were outsiders to both national context and medical school accreditation. The benefits of insider research include access to relevant stakeholders, documents, and experiential knowledge. For every insider to a national context, there were several outsiders who probed, discussed, and asked for clarification.37 The study was primarily conducted in English, using English versions of national and international accreditation standards.
Document analysis followed an iterative process.38 First, in August 2015, we collected documents containing the latest English versions of accreditation standards from TMAC (2013 standards25), KIMEE (2014 standards30), and JACME (2016 standards36), as well as their reference international standards (see Table 1 for list of documents). In 2016, K.S. and J.A. compared these national standards against their respective international reference standards, using qualitative data analysis software (NVivo 10, QSR International, Melbourne, Australia) to code for differences between national and international reference standards. Through thematic analysis,39 these differences were grouped into four categories.40 National insider authors corroborated the results of the thematic analysis. Disagreements were discussed until all authors reached consensus that the four categories suitably covered why international standards were adapted across all three countries.
Our document analysis found that the domestic accreditation standards developed by national medical school accreditation bodies in Taiwan, South Korea, and Japan departed from their international reference standards when accounting for local specificities in medical education (see Table 1 for list of documents). Alterations, omissions, and additions to the reference standards reflected four broad categories of differences: structural, regulatory, developmental, and aspirational (Table 2).
In each country, we found instances of departure from reference standards that accounted for the structure of medical education in the national context, including matters of program length and entry, school governance, and classification.
Both the TMAC and JACME standards addressed the structure and length of medical education programs. Unlike U.S. postbaccalaureate-entry medical schools, nearly all of Taiwan’s medical schools are structured for undergraduate entry. Consequently, Taiwan’s medical schools incorporate liberal arts and medical humanities into the medical curriculum41 (TMAC Standards 126.96.36.199, 188.8.131.52, 2.3.0, 2.3.1, 2.3.2, 2.3.3, 2.3.17, 4.1.0). Similarly, in Japan, JACME standards specify that medical schools must provide two years of clinical training out of the six years of undergraduate study (JACME Standard 2.5).
In South Korea, KIMEE sought to address quality gaps between newer and older medical schools as well as private and public schools. KIMEE standards require schools to address membership, composition, and division of labor within “opinion-gathering organizations” and specify the weight of such organizations in college operations (KIMEE Standards 1-2-2 and 4-1-1).30 These standards were added to address concerns that private schools may not have accountable and representative governance structures.
All three national accrediting bodies considered school governance. For example, because of differences in levels of medical school deans’ authority in the United States and Taiwan, TMAC revised LCME standards delegating responsibility to the head official (TMAC Standard 1.3.3). Similarly, to enhance the accountability and representativeness of governance structures, KIMEE devised Standard 1-2-5, which specifies the makeup of official committees to ensure diversity and to guard against corruption. JACME Standard 7.4, “Involvement of Stakeholders,” affirms that staff from affiliated research institutes can participate in program monitoring and evaluation processes.
Each country’s medical system is situated within a unique regulatory and policy environment. In all three cases, the national accreditation bodies adapted standards to conform to new and preexisting national regulations. For example, TMAC amended an LCME standard to conform to an MoE regulation regarding the duration of Taiwan’s medical education program (TMAC Standard 184.108.40.206). TMAC created other standards that specify adherence to guidelines passed by Taiwan’s Ministry of Health and Welfare, such as the ministry’s accreditation for teaching hospitals (TMAC Standard 5.3.1) and guidelines for HIV-infected medical student interns (final-year medical students paid by hospitals as interns) (TMAC Standard 3.4.0).
KIMEE standards responded to government regulations that require Korean medical schools to have both internal and external auditing systems (KIMEE Standard 1-3-3). Schools are required to ensure that funds are allocated for education and not for other purposes (e.g., the construction of hospitals) because of a perceived lack of national regulation in this area. Furthermore, KIMEE Standard 2-2-3 states that an education committee that “directly develops, manages and evaluates the curriculum” should have an annual budget of at least 30 million won (approximately U.S. $27,000 in 2017).30 Moreover, direct expenses related to student education must constitute 5% or more of annual tuition per student (KIMEE Standard 2-4-5).
In Japan, government regulations place forensics within medical curricula. All doctors are required to issue certificates of death and may take part in postmortem inspections. As forensic medicine is not a requirement in the WFME standards, JACME Standard 2.4 states that the social science curriculum should include forensic medicine in compliance with the above-mentioned regulations.
Each of the three medical education systems has followed a unique trajectory of development. Standards in this category reflect how national histories have shaped medical education. For instance, medical education in Taiwan has been heavily influenced by the 2003 SARS epidemic, which revealed basic deficiencies in the primary care capabilities of Taiwanese physicians. Thereafter, a movement took place to reestablish primary care proficiency as an educational priority, which is reflected in TMAC Standard 2.3.0.
In the early 2000s in South Korea, a number of high-profile cases of falsified results in medical research attracted government attention. KIMEE therefore requires medical colleges to conduct annual training on research ethics and implement research ethics regulations (KIMEE Standard 4-3-6).
In Japan, there are serious issues regarding the scarcity of physicians in certain regions. For example, there are 0.4 physicians per 1,000 people in Northeast Japan compared with 11 per 1,000 in Tokyo.42 In an attempt to address shortages, JACME permits admission quotas to encourage admission of students from areas in need of more physicians (JACME Standard 4.2).
In each country, accreditors and medical educators have their own aspirations, emphases, and priorities for the future trajectory of their medical schools. This category includes standards that reflect the accrediting bodies’ aspirations in each country, including educational philosophies or organizational objectives relating to the organization and management of medical education institutions (e.g., efficiency, staff retention). Other standards may reflect ideological responses to globalization.
Across all three cases, national standards incorporated national educational objectives (e.g., pedagogy, content curriculum, schools of thought). TMAC added standards on innovations in instruction methods (TMAC Standard 220.127.116.11) such as case learning, problem-based learning (PBL),43,44 and the use of standardized patients in assessments.45 KIMEE promoted the use of diverse education methods such as PBL (KIMEE Standard 2-2-4), reflecting a paradigm shift toward competency-based education.29 JACME specified that skills training in a clinical setting should involve patient contact beginning in the junior years and participation-based clinical training in the senior years, reflecting a global shift toward promoting early exposure to patients in clinical settings (JACME Standard 2.5). Also, JACME annotations reference Japan’s Medical Education Model Core Curriculum, in which clerks learn skills such as patient interviews, physical examination, clinical reasoning, and medical professionalism.
Standards were also added to reduce inequalities between different groups in medical schools. For example, TMAC sought to empower students (TMAC Standard 1.4.2), who in Taiwan have traditionally been passive receivers of education, the lowest rung on the hierarchical ladder. Moreover, the TMAC standards feature specific guidance with regard to implementing gender equity (Standards 1.1.01, 2.3.16, 3.4.0, 5.3.0), student counseling (Standard 18.104.22.168), learning portfolios (Standard 3.5.0), and staff retention (Standard 4.0).
The social implications of medical education were also considered. KIMEE developed standards explicitly focused on social accountability using a definition set by the World Health Organization.46 For example, KIMEE Standard 1-1-3 states that a college’s education, research, and patient care policies should be related to social accountability. In Japan, the medical education system is intended to be suitable for students wanting to pursue a variety of careers, such as researchers, community health providers, and civil servants. To encourage a wider range of career outlooks, JACME Standard 4.1, “Admission Policy and Selection,” stipulates an alternative student admission quota for recommendation-based and graduate-level entry in addition to the general quota of undergraduate-entry students selected through examination and interview.
The study aimed to explore medical school accreditation in Japan, South Korea, and Taiwan, yielding insights on how national accreditation bodies craft standards to address local needs amid the move toward global accreditation and, in these three cases, the extent to which each country did so.
All three countries used external standards in response to the 2010 announcement of the ECFMG-WFME initiative.6 Each country followed its own rationale in adopting or adapting external standards. While Japan directly adopted WFME standards with some annotations, South Korea and Taiwan implemented greater changes in the content of their reference standards. Japan’s adaptation of standards with minimal changes could be attributed to the relative youth of its accreditation system and the pressure to achieve international recognition. At the time of writing in 2017, KIMEE was in the process of revising its standards using the WFME 2015 standards33 as a template, perhaps presaging a shift toward external standards as 2023 draws closer.
Whether the glocalization of medical school accreditation standards in these three cases has been successful in addressing local problems (or needs) was not directly addressed in this study. However, there is some evidence of the effectiveness of the glocalized standards in each country. In Taiwan, accreditation has produced measurable quality improvements, partly through reinforcement of liberal arts and humanities, better coordination between medical schools and teaching hospitals for clinical education, and regular monitoring of new medical schools. In South Korea, research by independent education researchers, the Korean Association of Medical Colleges, and KIMEE has demonstrated that medical school accreditation improved curricula and faculty capacity. In Japan, accreditation has addressed a detrimental bias among medical school professors for clinical work and scientific research over teaching. The Japanese medical schools that underwent pilot accreditation processes all reported significant improvement in their overall education programs.
Glocalization involves a mix of local and global actors. Other studies exploring accreditation have strongly advocated consultation with a variety of local, regional, and international actors as central to the developmental process.14 The high degree of glocalization observed in Taiwan’s standards could be explained by TMAC’s extensive consultation with both local and global stakeholders during standards development. Further research into how consultations inform standards and accreditation procedures, as well as how global and local considerations are mediated, could shed further light on consultation processes and outcomes.
This study illustrates the complexity of developing accreditation standards that meet both local and global needs. We identified four categories of differences between local and global reference standards, reflecting local needs taken into account by accrediting bodies: structural, regulatory, developmental, and aspirational differences. These four categories could be considered a framework for understanding and testing glocalization of medical school accreditation. This framework could be developed and tested in future research in different settings and inform accreditation in national contexts as a signposting checklist.
Despite the potential value of this framework, we caution against oversimplifying the difference between the global and local contexts. An example is TMAC’s drafting of humanities-related standards. On the one hand, these standards constitute a long-pending response to an undergraduate-entry and professionally oriented system. On the other hand, these additions were proposed by TMAC members who had been exposed to liberal arts education in the United States and were inspired to advocate for greater inclusion of humanities in medical school curricula. This exemplifies “glocal entanglement”47: the indigenization of the global and the internationalization of the local—in short, glocalization.
Other factors are likely to influence glocalization in accreditation. Our research found evidence of regionalism as an emerging force in medical school accreditation. During JACME’s standards development process, members of the Japanese accrediting body paid visits to South Korea and Taiwan. South Korea’s KIMEE chose the WFME standards as one of its references to enable easier cross-comparison with its regional neighbors, China and Japan. A potential way forward may be sharing the accreditation process across a whole region, as governments in the Caribbean Community did with the Caribbean Accreditation Authority for Education in Medicine and Other Health Professions (CAAM-HP). Coestablished by national governments in a heterogeneous world region, CAAM-HP fulfills regional and local needs for a government-recognized quality assurance agency.48 Our study itself is a manifest example of regional collaboration between colleagues in Taiwan, South Korea, and Japan, who worked in their native languages domestically and in English in this international collaboration. This study may spur further regionalist collaboration and engagement. Regionalization, as a topic of research in medical education, deserves more attention alongside its close kin, globalization and localization.
This study has some limitations. The ongoing development of accreditation systems in each country may soon render our descriptions of their standards outdated. Temporal validity is an issue with qualitative research in general, and more so in a time of rapid globalization and change. For example, partway through this study in 2017, KIMEE began revising its standards to reference the WFME 2015 standards. Nevertheless, the four categories of differences are likely to remain relevant. In addition, by focusing on variations between countries, we did not account for within-country variations in medical education.49 However, because medical school accreditation takes place at the national level, it follows that the country is the most appropriate unit of analysis. Future research could explore the contextual application of standards and evaluate the degree to which they satisfy local needs within countries.7
As the movement to establish a reference standard for global accreditation gains momentum, it is important that medical educators reflect on the diverse sociocultural contexts in which global standards are applied. At the macro level, future studies may map trends in accreditation using the glocal and regional frames of analysis developed in this study. At the micro level, research can examine the thought and reasoning processes behind accreditation development, including whether and how actors prioritize among global and local considerations. Further studies comparing countries’ accreditation processes (e.g., site visits, report writing, decision making, post facto monitoring) are warranted as well.
This study explored how three countries in East Asia adapted external standards in response to the call for a global system of medical school accreditation.5,6 These countries’ glocalization of accreditation standards serve as examples for others seeking to bring their accreditation practices in line with global standards while ensuring that local cultural values and societal needs are given adequate consideration. Educators and accreditors may seek to account for structural, regulatory, developmental, and aspirational differences in medical education across countries. In conclusion, we encourage the medical education community to think critically about accreditation, with the goal of developing medical schools that meet both global quality standards and local societal needs. A systematic approach whereby local needs are mapped using the categories identified in this study could serve as a useful starting point.
The authors wish to thank Xan Liddy Faber for editorial assistance and staff at the Taiwan Medical Accreditation Council and Korean Institute of Medical Education and Evaluation for providing information.
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